CMS on Friday proposed mandatory minimum staffing requirements for skilled nursing facilities (SNFs). Advisory Board's Monica Westhead dives into the three key things you need to know: Why CMS set challenging — but attainable — requirements, the challenges this poses for SNFs moving forward, and how this mandate could impact other sites of care.
While insufficient staffing has been a longstanding concern for SNFs, high mortality rates during the COVID-19 pandemic underscored the consequences of inadequate staffing levels. In February 2022, the Biden administration announced plans to set new minimum requirements for SNF staffing levels.
Typically, staffing levels and requirements are specified as direct care hours per resident day (HPRD), which is calculated using the total number of hours worked by each type of nursing staff divided by the total number of residents in a facility.
In February 2022, the Biden administration announced plans to set new minimum requirements for SNF staffing levels. In April, the Biden administration issued an executive order directing the secretary of HHS to promote sufficient staffing levels and reduce turnover at SNFs.
For months, industry stakeholders have voiced mixed views on a staffing mandate, with patient advocates pushing for higher standards and SNFs expressing concern over unattainable requirements amid persistent staffing challenges.
Last week, in a report commissioned by CMS, Abt Associates said that there was "no obvious plateau at which quality and safety are maximized or 'cliff' below which quality and safety steeply decline."
While the report did not make any recommendations on appropriate staffing ratios, it estimated that higher staffing levels would result in decreased hospitalizations and ED visits, quicker care, and decreased failures to provide care.
After the report's release, some stakeholders said the findings do not support CMS' efforts to implement mandatory staffing ratios.
Then, CMS on Friday issued its highly anticipated mandatory minimum staffing requirements for SNFs. Under the rule, each resident would be required to receive 2.45 HPRD from a nurse aid, and 0.55 HPRD from an RN. In addition, the rule calls for facilities to have an RN on site all day, every day.
The Biden administration's proposed mandate has garnered both support and criticism from industry stakeholders.
The American Health Care Association (AHCA), which lobbies on behalf of care facilities, said the proposal is "unfathomable," adding that it will exacerbate existing problems and cost nursing homes billions of dollars.
While government reports indicate that the average U.S. nursing home currently has overall staffing levels of roughly 3.6 HPRD, including RN staffing levels just above the 30-minuite mark, most nursing homes would have to hire additional staff under the proposed mandate.
"We hope to convince the administration to never finalize this rule as it is unfounded, unfunded, and unrealistic," said AHCA President Mark Parkinson.
Meanwhile, CMS Administrator Chiquita Brooks-LaSure, noted that the mandate is "an important first step."
"Establishing minimum staffing standards for nursing homes will improve resident safety," HHS Xavier Becerra said in a statement. "When facilities are understaffed, residents suffer."
According to a senior White House official, the Biden administration is open to revisiting the required staffing levels once the mandate is implemented.
"I would caution anyone who thinks that the status quo – in which there is no federal floor for nursing home staffing – is preferable to the standards we're proposing," said Stacy Sanders, an aide to Becerra. "This standard would raise staffing levels for more than 75% of nursing homes, bringing more nurse aides to the bedside and ensuring every nursing home has a registered nurse on site 24/7." (Rau, KFF Health News, 8/29; Eastabrook/Berryman, Modern Healthcare, 8/31; Eastabrook/Berryman, Modern Healthcare, 9/1; Rowland, Washington Post, 9/1; Sedensky, Associated Press, 9/1)
By Monica Westhead
While the long-awaited SNF staffing mandate is a meaningful step to promoting quality improvements, just as we anticipated, its staffing requirements are not especially aggressive.
As it stands, most organizations will likely be able to comply with the mandate. We weren't surprised by the relatively modest proposed requirements because CMS was tasked with walking an exceptionally challenging tightrope when setting them.
The agency had to balance the need to improve staffing and quality of patient care across the SNF industry amid rising patient acuity with the reality of a cross-continuum staffing shortage that hits SNFs hardest. These targets were likely chosen with the goal of improvement without posing an existential threat to SNFs' ability to operate and serve their communities.
Overall, industry feedback seems to reflect the knowledge that the staffing mandate will be challenging for many — but is not as burdensome as feared.
For many SNFs, the most difficult element will be the RN-specific staffing requirement. Not all SNFs currently employ RNs to cover 24 hours/day, and many are located in markets where it will be very difficult to source more RNs. This is reflected in the proposed timeline in the rule. For example, SNFs in rural settings are allowed more time to meet the staffing requirements than those in urban settings.
Still, all SNFs will need to focus on recruiting and retention efforts — including pay and benefits, flexibility, and work-life balance — to shore up and sustain their staff in a competitive staffing environment.
Currently, this mandate is a proposed rule. We will be watching to see whether any changes are made before the final rule is released, whether to tighten or loosen the requirements.
We're also keeping our eye on the long-term impact of the mandate beyond the SNF setting. Should this progress to final rule stage and be implemented, it could represent a model for CMS to introduce mandatory staffing levels for other sites of care.
The impact of staffing mandates on clinical outcomes, hospital operations, and nurses themselves has been often debated in the 20 years since California established mandatory ratios in hospitals there.
As CMS tracks the outcomes associated with the SNF mandate, the available data will expand, potentially tipping more states in the direction of passing similar laws, or even leading CMS to set national benchmarks.
Learn more about recruitment and retention in the SNF setting with The Post-Acute Leader's HR Guide (advisory.com)
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